http://e-journal.unair.ac.id/JNERS | 345 

 

Jurnal Ners 
Vol. 14, No. 3, Special Issue 2019 
http://dx.doi.org/10.20473/jn.v14i3(si). 17313 

This is an Open Access article distributed 
under the terms of the Creative Commons 

Attribution 4.0 International License  

Original Research 

Attitude of Nurses Related to The Implementation of Patient Safety in The Intensive 
Care Unit 

Hanik Endang Nihayati1, Gunawan Gunawan2, Erna Dwi Wahyuni1, Sena Wahyu Purwanza1, and 
Hidayat Arifin1 

1Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia 
2Intensive Care Nurses, Pelindo Husada Citra Hospital, Surabaya, Indonesia 

ABSTRACT 

Introduction: The error events in the Intensive Care Unit (ICU) were caused 
by nurses focusing more towards collaborative intervention with other 
medical staff and workload documentation which was not optimal. The 
purpose of this study was to determine the predisposing factors related to 
the implementation of patient safety in the ICU. 

Methods: This study was a descriptive analytic correlational study. Sample 
size was determined by purposive sampling and obtained 26 nurses. The 
independent variables were the predisposing factors and the dependent 
variable was the implementation of patient safety.  Instruments used were 
a questionnaire and observation sheet. Analysis was performed using 
Spearman's Rho and Logistic Regression.  

Results: Spearman’s Rho showed there was a significant correlation 
between knowledge (p=0.019) and attitude (p=0.040) towards 
implementation of patient safety. There was no significant of motivation 
(p=0.073) towards the implementation of patient safety. Logistic Regression 
showed the dominant factor in implementation of patient safety was 
attitude. 

Conclusion: Predisposing factors, that include knowledge and attitude, had 
a significant effect on the implementation of patient safety, but still required 
high motivation in the implementation of patient safety. In addition to 
knowledge and good attitude, nurses are expected to improve motivation in 
the implementation of patient safety.   

ARTICLE HISTORY 

Received: Dec 26, 2019 
Accepted: Dec 31, 2019 

KEYWORDS 

patient safety; attitude; knowledge; 
attitude 

CONTACT 

Sena Wahyu Purwanza  
 sena.wahyu.purwanza-
2018@fkp.unair.ac.id   
 Faculty of Nursing, Universitas 
Airlangga, Surabaya, Indonesia 

Cite this as:  Nihayati, H.E., Gunawan, G., Wahyuni, E.D.,, Purwanza, S.W., & Arifin, H. (2019). Attitude of Nurses Related to 
The Implementation of Patient Safety in The Intensive Care Unit. Jurnal Ners, 14(3si), 345-350. 
doi:http://dx.doi.org/10.20473/jn.v14i3(si).17313 

 

INTRODUCTION  

Predisposing Factors on emergency patients in the 
Intensive Care Unit (ICU) occur in the first 48 hours. 
The incidence of errors in the Intensive Care Unit 
(ICU) is because nurses are more focused on handling 
and collaborating with other medical personnel so 
that nursing documentation is not optimal. This 
occurs because nurses experience an increase of 
workload so that they make errors when carrying out 
their job (Roque, Tonini, & Melo, 2016). Error events 
in the ICU in terms of documentation can occur due to 
nurse communication (documentation) that running 
poorly which can caused errors in documentation 

that are not accordance with the standards 
(Nursalam, 2018). 

These error events can cause Unexpected Events 
(UE) including misidentification of patients, errors in 
communication when nursing handover and 
receiving advice from other health workers, errors in 
administration of drugs, especially high alert drugs, 
and the incidence of infections that occur in the ICU 
room(Dhabi, 2008); (International, 2014);(Nursalam, 
2018)). Based on data from the Ministry of Health in 
Indonesia the incidence of violations of patient safety 
carried out by nurses is 28.3% (Kementrian 
Kesehatan, 2013). Reports of patient safety incidents 
in Indonesia there were 55 cases (37.9%) occurring 
in the DKI Jakarta area, while based on their type 

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there was a prevalence of KNC types (Near Injury 
Events) as many as 69 cases (47.6%), 67 cases (46 , 
2%), and others 9 cases (6.2%). Error events that 
occur in hospitals is decreasing quality of nurses due 
to stress caused by an increase in workload by 74% 
(Muthmainah, 2012). 

According to the Health Ministry of Regulation 
Clause 8 No. 1691 of 2011 concerning Hospital 
Patient Safety which includes the accuracy of patient 
identification, improvement of effective 
communication, increased safety of drugs that need to 
be watched out, nurses ensure the right location, the 
right procedure, the right patient when the surgery is 
carried out, reduction the risk of infection related to 
health services, and reduction of patient falls risk. 
However, based on the preliminary survey data 
obtained by researchers in the ICU room at the PHC 
Hospital in Surabaya, there were still nurses who did 
not implement the Patient Safety Program. 
Preliminary data carried out by researchers in the ICU 
of PHC Hospital Surabaya conducted in November 
2016 was obtained through observations related to 
patient safety actions, of the 10 morning shift nurses 
there were 4 who did not wash their hands before 
touching patients, 3 nurses did not identify patients 
and 3 nurses who do not put up a patient indicator of 
the risk of falling in bed. 

Health services provided by health and non-health 
workers are increasingly complex along with the 
development of science and technology. This allows 
unwanted events to occur if the complexity is not 
managed properly. Error events occur a lot on nurses 
because of the high workload and collaboration with 
other health workers. This can cause unwanted event 
which can have an impact on patient safety. The 
consequences of patient safety that do not do 
correctly and precisely are the occurrence of infection 
in patients, errors in drug administration and 
interventions that can caused disability and even 
death in patients (Caesarityanti, 2011).  

Efforts to prevent the occurrence of UE resulting 
in patient safety, it is necessary to make Standard 
Procedure Operation (SPO) and the culture of "seven 
steps towards patient safety" which are expected to 
reduce the patient's safety rate. The application of 
SPO in principle is part of the performance and 
behavior of individuals in working accordance with 
their duties in organization and this is usually related 
to the compliance of nurses in carrying out nursing 
actions based on SPO that has been determined. The 
researcher used guidelines from the implementation 
of Hospital Accreditation Commission patient safety 
in conducting observations, that is identifying of 
patients correctly, improving effective 
communication, increasing drug safety, ensuring the 
right location, right procedures, appropriate patients, 
reducing the risk of infection and reducing the risk of 
falls. One of the factors that influence a person's 
compliance is knowledge, age, education, and 
motivation (Notoadmodjo, 2012). This is in 
accordance with Lawrence Green's theory which 
analyzes human behavior from the level of health, 

which suggests that behavior is formed by several 
factors, one of them is predisposing factors which 
include knowledge, attitudes, and motivation. Based 
on the description above, nurses have an important 
role in providing comprehensive care, one of which is 
through the implementation of patient safety. 
Therefore, researchers wanted to know the 
predisposing factors with the implementation of 
patient safety in the ICU room at the PHC Hospital 
Surabaya. 

MATERIALS AND METHODS  

This study was described correlational analytic 
design. The population in this study were all nurse 
who had work in Intensive Care Unit PHC Hospital, 
which were 32 nurse. The sample in this study were 
nurse work in ICU PHC Hospital with inclusion and 
exclusion criteria and obtained 26 nurse. Inclusion 
criteria in this study include; 1) nurses who work in 
ICU PHC Hospital at least 1 year, 2) nurses who have 
attended patient safety socialization. While the 
inclusion criteria include: 1) nurses during maternity 
leave, 2) nurses who currently attending patient 
safety training or outside education PHC Hospital 
Surabaya. The sampling technique in this study used 
a non-probability sampling technique with the type of 
purposive sampling. The independent variable were 
the nursing factor (factor predisposing) which 
include knowledge, attitudes and nurses motivation, 
while the dependent variable was implementation of 
patient safety. 

Knowledge questionnaire 
The knowledge questionnaire in this study was about 
implementation of patient safety of 15 questions. If 
the respondent answers the question correctly, it will 
get a value of 1 and if the respondent answers 
wrongly gets a value of 0. Then the researcher makes 
a classification of the level of knowledge from the 
respondent's answer, namely: good: 76-100 %, 
sufficient: 56 - 75%, and less: ≤ 56 %.   

Attitudes questionnaire 
The attitude instrument used in this study was a 
questionnaire about nurses' attitudes towards the 
implementation of patient safety in 30 questions. If 
the respondent answers correctly, he gets a score of 1 
and 0 if the answers incorrect. Then, the researcher 
will classify the attitude classification, namely good 
attitude> 75 and less good attitude <75. 

Motivation questionnaire 
The motivational instrument in this study was using a 
questionnaire about nurses' motivation towards the 
implementation of patient safety in 15 questions. 
Scores for positive questions: SS = 4, S = 3, TS = 2, STS 
= 1. Scores for negative questions: SS = 1, S = 2, TS = 3, 
STS = 4. Then, researchers will classify the 
classification of motivation levels, namely strong 
motivation: 76% -100%, moderate motivation: 56% -
75% and weak motivation ≤ 55%. 



JURNAL NERS 

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Instrument of patient safety implementation 
The instrument of patient safety implementation in 
this study uses an observation sheet about the 
implementation of patient safety. The number of 
components observed is 17 components. 
Respondents will get 1 score when they doing patient 
safety and 0 if patient safety is not done. Then, the 
researcher will classify the classification of patient 
safety implementation, which is good 
implementation:> 76% and less implementation 
<75%. 

Procedures 
Data collection was done by determining the 
population of 32 nurses in the ICU of PHC Hospital 
Surabaya, then selecting samples according to 
inclusion criteria and obtained a sample of 26 nurses, 
followed by sharing informed consent to 
respondents, then distributing questionnaires to a 
sample of 26 respondents in the room ICU Surabaya 
PHC Hospital. The questionnaire was distributed at 
the time of respondent's rest hour, then the 
respondent was asked to fill out the questionnaire 
accompanied by the researcher so that there was no 
bias (cheat sheet when filling out the questionnaire). 
After the results were obtained from the 
questionnaire, then the researchers began to observe 
at least 2 nurses related to the implementation of 
patient safety which includes the accuracy of patient 
identification, increased effective communication, 
increased drug safety to watch out for, nurses ensure 
the right location, right procedure, right patient 
before surgery, reduction the risk of infection related 
to health services, and reduction of the risk of falling 
patients performed in the ICU PHC Hospital in one 
shift as much as twice, so that researchers make 
observations on morning or afternoon shifts. 

Analysis 
This study uses a data analysis test to analyze related 
factors to the implementation of patient safety 
programs in the ICU room at PHC Surabaya Hospital. 
The scale obtained is ordinal through a questionnaire. 
The data obtained will be collected and analyzed by 
statistical tests using the Spearman Rank (Rho) 
correlation test to determine whether there is a 
relationship between predisposing factors and the 
implementation of patient safety. The basis of 
decision making is based on 95% confidence level or 
α = 0.05.). The strength of the relationship is 
expressed in the magnitude of the coefficient 
correlation p ≤ α (0.05) which means that there is a 
meaningful relationship between the two measured 
variables, namely predisposing factors with the 
implementation of patient safety. If p ≤ α (0,05) then 
H0 is rejected and H1 is accepted. 

Ethical consideration 
This research will begin by carrying out several 
procedures related to research ethics including 
informed consent, anonymity, confidentiality. The 
committee of ethical approval in the Faculty of 

Nursing Universitas Airlangga give approved the 
above mentioned protocol with number 264-KEPK. 
 

RESULTS  

The results of the knowledge of respondents with the 
implementation of patient safety from 26 
respondents. The majority of respondents' 
knowledge with sufficient knowledge categories can 
do patient safety in a good category. However, there 
are still respondents with sufficient knowledge in the 
implementation of patient safety is still not good. The 
results show there are respondents with less 
knowledge, but in the implementation of good patient 
safety. 

The relationship between the level of respondents 
'knowledge about patient safety towards the 
implementation of patient safety and the Spearmen's 
Rho test shows that there is a relationship between 
respondents' knowledge of the implementation of 
patient safety in the Intensive Care Unit (ICU) in PHC 
Surabaya Hospital with a moderate correlation level 
and a positive correlation coefficient indicating that 
there is a relationship between the variable that is in 
the same direction with the same high value. 

The results of the attitudes of respondents with 
the implementation of patient safety from 26 
respondents. The majority of respondents with good 
attitude in the implementation of patient safety are 
also good. Meanwhile, there are respondents with a 
bad attitude, but in the implementation of patient 
safety in the good category. 

The relationship of the respondent's attitude 
towards the implementation of patient safety with the 
spearmen's rho test shows that there is a relation 
between the respondent's attitude towards the 
implementation of patient safety in the Intensive Care 
Unit (ICU) Room of PHC Hospital with a moderate 
correlation level and a positive correlation coefficient 
that shows the relationship between the two 
variables in the same direction the same height value. 

The results between the motivations of 
respondents with the implementation of patient 
safety from 26 respondents. The majority of 
respondents with strong motivation in implementing 
patient safety are in a good category, but there are still 
respondents with strong motivation, but with poor 
implementation of patient safety. 

The relationship of respondents 'motivation 
towards the implementation of patient safety with the 
Spearmen's Rho test showed that there was no 
correlation between respondents' motivation 
towards the implementation of patient safety in the 
Intensive Care Unit (ICU) Room of the Surabaya PHC 
Hospital with a low correlation level and a positive 
correlation coefficient that showed a relation 
between two directional variables with the same high 
value. 

The results of candidate selection were carried out 
using a simple logistic regression test. The 
requirement to enter the multivariate analysis model 



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is p-value ≤ 0.25. The results show that predisposing 
factors (knowledge, attitude, and motivation) meet 
the requirements to enter the multivariate analysis 
model. 

The results showed that attitude was the most 
influential factor with the implementation of patient 
safety in the Intensive Care Unit (ICU) Room of the 
Surabaya PHC Hospital 13,940 times influential in 
patient safety implementation. 

DISCUSSION 

Respondents' knowledge about patient safety in 
the Intensive Care Unit (ICU) Room of the 
Surabaya PHC Hospital was mostly at a sufficient 

level, but there were also those who lacking 
knowledge. The more advanced of science and 
technology that continues to evolve, the learning 
process to increase knowledge must be continue. 
The Intensive Care Unit (ICU) is equipped with 
adequate mechanical facilities and equipment, so 
that the existence of respondents as health 
workers must really master the operation of 
tools, care, willingness to always learn to 
increase knowledge and creativity and change 
the behavior of respondents as health workers in 
the better direction is needed in the 

implementation of patient safety. 

             

Table 1. Distribution of Results between the Categories of Knowledge and Implementation of Safety Patient  

Knowledge Value 
 Patient safety Implementation 

∑ 
Good  Less good 

f(x) % f(x) % f(x) % 
1. Good 
2. Sufficient 
3. Less 

4 
14 
1 

15.4 
53.8 
3.8 

0 
5 
2 

0 
19.2 
7.7 

4 
19 
3 

15.4 
73.1 
11.5 

         ∑ 19 73.1 7 26.9 26 100 
(p): 0.019 ≤ 0.05 (r): 0.457 

         
 Table 2. Results Distribution between Attitude Categories and Implementation of Safety Patient  

Attitude Value 
Patient safety implementation 

∑ 
Good Less Good 

f(x) % f(x) % f(x) % 
1. Good 
2. Not Good 

17 
2 

65,4 
7,7 

2 
5 

7,7 
19,2 

19 
7 

73,1 
26,9 

        ∑ 19 73,1 7 26,9 26 100 
(p): 0,040 ≤ 0,05 (r): 0,405 

 

 
Table 3. Results Distribution between Motivation Categories and Implementation of Safety Patient  

Nilai Motivasi 
Patient safety implementation 

∑ 
Good Less Good 

f(x) % f(x) % f(x) % 
1. Strong  
2. Sufficient  
3. Weak  

10 
9 
0 

38,5 
34,6 

0 

2 
4 
1 

7,7 
15,4 
3,8 

12 
13 
1 

46,2 
50 
3,8 

        ∑ 19 73,1 7 26,9 26 100 
(p): 0,073 ≥ 0,05 (r): 0,358 

 

Table 4. Factors predisposing Distribution of candidate selection to the implementation of patient safety 

Variable p-value 
Knowledge 0,082 

Attitude  0,006 
Motivation 0,147 

  

Table 5. Significant Levels of Independent Variables Against Dependent Variables Distribution  

Predisposing Factor Wald p-value OR 

Knowledge 0.93 0.760 1.507 
Attitude  3.811 0.051 13.940 
Motivation 0.527 0.468 2.166 
Constant 3.317 .069 .002 

 

 



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Knowledge or cognitive is a very important 
domain in the formation of a person's actions 
(overt behavior). Knowledge is defined as 
intellectually knowledge with facts, truths / 
principles added to observations, and 
experiences and reporting (Notoadmodjo, 
2012). The learning process is not only directly 
obtained from formal education or informal 
education. Lack of knowledge can be caused by 
the process of acceptance and understanding of 
the information obtained that still not maximal. 
One of the way that can be done to increase 
knowledge that is useful is, doing conducting 
socialization to improve the effectiveness in 
achieving the work results set for safety and 
satisfaction. Patient safety socialization is 
included in the policy of implementing patient 
safety at Surabaya PHC Hospital through 
education, training and research. 

The results of research conducted by 
researchers showed a significant relation 
between attitudes towards the implementation 
of patient safety. This is supported by data 
distribution of attitude categories which shows 
that most respondents have good attitude 
towards the implementation of patient safety, as 
well as length of work data majority of the 
respondents have working experience for 6-10 
years, so that they have enough experience in 
implementing patient safety. However, there are 
still some respondents in the sufficient category 
during the implementation of patient safety, this 
may be influenced by culture, quality of life, 
influence of people who are considered 
important, or may be influenced by the personal 
experience of respondents based on the length of 
time in the Intensive Care Unit (ICU) Surabaya 
PHC Hospital. 

Lawrence Green's (1980) theory which states 
that one of the factors that influence behavior is 
attitude as a predisposing factor. Walgito (2003) 
expressed his opinion that in order to change 
attitudes, people generally will change their 
cognitive components first so that the affective 
component will eventually change. Some other 
factors that influence attitudes according to are 
personal experience, culture, other people who 
are considered important, mass media, 
educational institutions or institutions, religion, 
and individual factors (Azwar, 2002). 

Data distribution of respondents' motivation 
categories obtained by researchers shows that 
the majority of respondents' motivation are in 
the sufficient category, and most of the 
respondents' motivation is in the strong 
category. This is very different from the opinion 

which says that good motivation will be followed 
by a change in good attitude, in this case the 
implementation of patient safety. Meanwhile, 
respondents' motivation was good but there was 
no relationship with the implementation of 
patient safety in the Intensive Care Unit (ICU) 
Room of the PHC Hospital in Surabaya. 

This can be caused by respondents show 
different performance in providing nursing 
services due to motivation. This is also included 
in the implementation of patient safety. 
Respondents are motivated by physiological 
needs, safety, attention and love, self-esteem and 
self-actualization. Respondents were also 
affected by co-cognitive needs for knowledge 
(Kanagasabai, 2013). According to the theory of 
needs, the motivation of someone comes when 
they have not reached a certain level of 
satisfaction in their lives. Satisfied needs will no 
longer be a motivator. 

The results of the analysis using multiple 
logistic regression tests showed that attitude 
was the most influential factor with the 
implementation of patient safety in the Intensive 
Care Unit (ICU) Room of the Surabaya PHC 
Hospital with 13,940 influential times in the 
implementation of patient safety. Lawrence 
Green's (1980) theory which states that factors 
that influence behavior one of them is attitude as 
a predisposing factor. Zimbardo & Ebbesen in 
Ahmadi (1999) states that attitudes are a 
predisposition to an individual, an object that 
contains components - cognitive, affective, and 
behavioral components. The limitations of this 
study are that questionnaires from 
questionnaires conducted by respondents were 
directed by the researcher directly, allowing 
respondents to experience pressure when filling 
out questionnaires, as well as data retrieval 
techniques carried out in a momentary manner, 
making it less representative of the research 
results. 

CONCLUSION 

Predisposing factors (knowledge and attitude) have a 
significant relationship with patient safety 
implementation in Intensive Care Unit (ICU) Room 
PHC Hospital Surabaya. But good predisposing 
factors (motivations) do not necessarily influence the 
implementation of patient safety in Intensive Care 
Unit (ICU) Room PHC Hospital Surabaya, this can be 
caused by several factors such as knowledge and 
length of work experience. The most dominant and 
influential predisposing factor of the implementing 
patient safety is the attitude of nurses. The 
implication of the research to increase patient safety 
implementation and quality nursing care. 



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350 | pISSN: 1858-3598  eISSN: 2502-5791 

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